A 71-year old gentleman presented with history of two episodes of syncope. The baseline ECG is shown in Fig. 1. The 2D-echocardiography and coronary angiography was normal. What is the ECG diagnosis?

The ECG shows an atrial rate of 88/min with two P waves for each QRS complex resulting in ventricular rate of 44/min. The P waves are positive in leads II, III, and aVf and biphasic in V1 suggestive of sinus node origin of atrial activity. Alternate P waves are not followed by a QRS complex (blocked) producing 2:1 atrioventricular (AV) block. The PR interval of the conducted beat is 0.18 seconds and is constant. The QRS complexes are wide (≥ 0.12 seconds) and are of RBBB morphology. Thus, the complete ECG diagnosis of the present case is sinus rhythm with 2:1 AV block and RBBB. 

Volume 1, Number 1, Page: 44-6

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